NOTICES

Provisions of Act 51 of 2010

[40 Pa.B. 5660][Saturday, October 2, 2010]

The act of July 9, 2010 (P.L. 362, No. 51) (Act 51), recently signed into law, added to the Commonwealth's long-term care insurance (LTCI) laws a provision granting a right to appeal an insurer's determination that a benefit trigger is not met. It also added definitions of ''benefit trigger'' and ''independent review organization.''

Under section 1111.1 of The Insurance Company Law of 1921 (act) (40 P. S. § 991.111a), as added by Act 51, benefit trigger determinations are subject to the right to an internal appeal and then to the right to an external independent review by an entity certified or approved by the Insurance Department (Department) to perform independent reviews of benefit trigger determinations. The Department will maintain and periodically update a list of certified LTCI independent review organizations on the Department's web site.

The provisions of Act 51 apply to benefit trigger requests made on or after November 6, 2010.

To comply with Act 51, each insurer is required to:

• For each determination on or after November 6, 2010, that the benefit trigger of an LTCI policy has not been met, provide written notice to the insured and the insured's authorized representative, if applicable. The notice must satisfy the requirements of section 1111.1(b) of the act.

• Follow the internal appeal process specified in section 1111.1(c), including providing a written description of the insured's right to request an independent review of the benefit determination.

• If an insured or the insured's authorized representative requests an independent review of the insurer's benefit trigger determination, follow the external review process specified in section 1111.1(d) of the act.

To facilitate timely dissemination of information regarding entities certified to review long-term care benefit trigger determinations in the Commonwealth, each long-term care insurer should provide the name, title, telephone number, fax number and e-mail address for contact persons at the company for these matters.

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